Event Notification Report for April 19, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/18/2021 - 04/19/2021
Agreement State
Event Number: 55186
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee:
Region: 3
City: Duluth State: MN
County:
License #: 1048
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Ossy Font
Licensee:
Region: 3
City: Duluth State: MN
County:
License #: 1048
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Ossy Font
Notification Date: 04/09/2021
Notification Time: 16:08 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/09/2021
Notification Time: 16:08 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/09/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PELKE, PATRICIA (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 4/19/2021
EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED GREATER THAN PRESCRIBED
The following was received from the Minnesota Department of Health via email:
"A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021.
"Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose [that varied by] greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days.
"The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED GREATER THAN PRESCRIBED
The following was received from the Minnesota Department of Health via email:
"A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021.
"Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose [that varied by] greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days.
"The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 55189
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Element Hotel
Region: 4
City: Superior State: CO
County:
License #: GL002594
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Element Hotel
Region: 4
City: Superior State: CO
County:
License #: GL002594
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 04/12/2021
Notification Time: 18:23 [ET]
Event Date: 12/11/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/12/2021
Notification Time: 18:23 [ET]
Event Date: 12/11/2020
Event Time: 00:00 [MDT]
Last Update Date: 04/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/20/2021
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITUM EXIT SIGNS
The following synopsis was received from the Colorado Department of Public Health and Environment via email:
During an inventory, a hotel manager discovered two exit signs were lost, each containing 7.62 Ci of tritium.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST TRITUM EXIT SIGNS
The following synopsis was received from the Colorado Department of Public Health and Environment via email:
During an inventory, a hotel manager discovered two exit signs were lost, each containing 7.62 Ci of tritium.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Non-Agreement State
Event Number: 55190
Rep Org: United States Steel
Licensee: United States Steel
Region: 3
City: Gary State: IN
County:
License #: 13-26104-03
Agreement: N
Docket:
NRC Notified By: ShaKeia Reese
HQ OPS Officer: Brian Lin
Licensee: United States Steel
Region: 3
City: Gary State: IN
County:
License #: 13-26104-03
Agreement: N
Docket:
NRC Notified By: ShaKeia Reese
HQ OPS Officer: Brian Lin
Notification Date: 04/13/2021
Notification Time: 16:02 [ET]
Event Date: 04/13/2021
Event Time: 07:45 [EDT]
Last Update Date: 04/13/2021
Notification Time: 16:02 [ET]
Event Date: 04/13/2021
Event Time: 07:45 [EDT]
Last Update Date: 04/13/2021
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
STOEDTER, KARLA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
STOEDTER, KARLA (R3DO)
EN Revision Imported Date: 4/20/2021
EN Revision Text: STUCK SHUTTER
The following information was received from the licensee via email:
"At 0745 CDT, a Systems employee was in #14BF stock house performing lockout tagout procedures in preparation for an outage. As the employee was attempting to close the shutter on the north Berthold gauge, the handle broke leaving the shutter stuck in the open position. No personnel were exposed to the source. Under normal operating conditions the shutter remains open and doesn't pose an immediate hazard while following established procedures.
"Initial Corrective Actions:
- Performed a survey in the work area. No readings above background.
- Posted signage indicating that the shutter is inoperable, stuck in the open position, and informing employees not to enter.
- Contact manufacturer representative (Radiametrics) to schedule assessment and repairs."
The Berthold gauge contas a 300 milliCurie Am-241/Be source.
EN Revision Text: STUCK SHUTTER
The following information was received from the licensee via email:
"At 0745 CDT, a Systems employee was in #14BF stock house performing lockout tagout procedures in preparation for an outage. As the employee was attempting to close the shutter on the north Berthold gauge, the handle broke leaving the shutter stuck in the open position. No personnel were exposed to the source. Under normal operating conditions the shutter remains open and doesn't pose an immediate hazard while following established procedures.
"Initial Corrective Actions:
- Performed a survey in the work area. No readings above background.
- Posted signage indicating that the shutter is inoperable, stuck in the open position, and informing employees not to enter.
- Contact manufacturer representative (Radiametrics) to schedule assessment and repairs."
The Berthold gauge contas a 300 milliCurie Am-241/Be source.